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Direct confirmation that long-term EC use leads to reductions in smoking-related diseases is not available and it will take a few decades before the tobacco harm reduction potential of this products is firmly established. Nonetheless, it is feasible to detect early changes in airway function and respiratory symptoms in smokers switching to e-vapor.

Summary

Abstract

Electronic cigarettes (ECs) have been rapidly gaining ground on conventional cigarettes due to their efficiency in ceasing or reducing tobacco consumption, competitive prices, and the perception of them being a much less harmful smoking alternative. Direct confirmation that long-term EC use leads to reductions in smoking-related diseases is not available and it will take a few decades before the tobacco harm reduction potential of this products is firmly established. Nonetheless, it is feasible to detect early changes in airway function and respiratory symptoms in smokers switching to e-vapor. Acute investigations do not appear to support negative respiratory health outcomes in EC users and initial findings from long-term studies are supportive of a beneficial effect of EC use in relation to respiratory outcomes. The emerging evidence that EC use can reverse harm from tobacco smoking should be taken into consideration by regulatory authorities seeking to adopt proportional measures for the e-vapor category.

Keywords:

Background

The electronic cigarette (EC) has been rapidly gaining ground on conventional cigarettes and could surpass consumption of conventional cigarettes within the next decade, according to some prediction analyses [1]. The growing popularity of ECs proves that many adult smokers are keen on using an alternative technologic form of smoking to reduce cigarette consumption or quit smoking and to relieve tobacco withdrawal symptoms [2]. Data from internet surveys [2],[3] and clinical trials [4],[5] have shown that ECs may help smokers quit or reduce their tobacco consumption. Moreover, the popularity of ECs appears to be associated with the fact that they can be used in many smoke-free areas, their prices are competitive, and they are perceived as a much less harmful smoking alternative [3],[6].

Vapor toxicology under normal conditions of use is by far less problematic than that of conventional cigarettes [7], and exclusive EC users have significantly lower urine levels of tobacco smoke toxicants and carcinogens compared to cigarette smokers [8]. Thus, smokers completely switching to regular EC use are likely to gain significant health benefits.

Although a reduction in smoking-related diseases from long-term EC use can be inferred by the positive findings on Swedish snus (a tobacco harm reduction product consisting of refined oral tobacco which is low in nitrosamines) [9], direct confirmation is not available and it will take a few decades before a reduction in individual and population health outcomes due to the regular use of e-vapor products can be firmly established. Nonetheless, it is feasible to detect early changes in airway function and respiratory symptoms in smokers switching to e-vapor.

In this commentary, I discuss the emerging potential of ECs for harm reversal with a specific focus on the respiratory system.

Conclusion

Compared to combustible cigarettes, e-vapor products are at least 96% less harmful and may substantially reduce individual risk and population harm [22]. Future research will better define and further reduce residual risks from EC use to as low as possible by establishing appropriate quality control and standards. Although large longitudinal studies are warranted to elucidate whether ECs are a less harmful alternative to tobacco cigarettes and whether significant health benefits can be expected in smokers who switch from tobacco to ECs, the emerging evidence that EC use can reverse harm from tobacco smoking should be taken into consideration by regulatory authorities seeking to adopt proportional measures for the e-vapor category [23].

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**Note: no analysis of Art18 wording. Could we extract info on lobbying by tobacco industry on Art18 (now 20)?**

The tobacco industry spends large sums lobbying the European Union (EU) institutions, yet whether such lobbying significantly affects tobacco policy is not well understood. We used novel quantitative text mining techniques to evaluate the impact of industry pressure on the contested EU Tobacco Products Directive revision.

Summary

Design Policy positions of 18 stakeholders including the tobacco industry, health NGOs and tobacco retailers were evaluated using their text submissions to EU consultations and impact assessments. Using Wordscores to calculate word frequencies, we developed a scale ranging from 0–tobacco industry to 1–public health organisations, which was then used to track changes in the policy position of the European Commission’s 2010 consultation document, its 2012 final proposal and the European Parliament and Council’s approved legislation in March 2014.

Results Several stakeholders’ positions were closer to the tobacco industry than that of health NGOs, including retailers (ω=0.35), trade unions (ω=0.34) and publishers (ω=0.33 and ω=0.40). Over time the European Commission’s position shifted towards the tobacco industry from ω=0.52 (95% CI 0.50 to 0.54) to ω=0.40 (95% CI 0.39 to 0.42). This transition reflected an increasing use of words pertaining to business and the economy in the Commission’s document. Our findings were robust to alternative methods of scoring policy positions in EU documents.

Conclusions

Conclusions Using quantitative text mining techniques, we observed that tobacco industry lobbying activity at the EU was associated with significant policy shifts in the EU Tobacco Products Directive legislation towards the tobacco industry’s submissions. In the light of the Framework Convention on Tobacco Control, additional governance strategies are needed to prevent undue influence of the tobacco industry on EU policy making.

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The 2014 European Union (EU) Tobacco Products Directive (TPD) was negotiated in a changed policy context, following adoption of the EU’s ‘Smart Regulation’ agenda, which transnational tobacco companies (TTCs) anticipated would increase their influence on health policy, and the WHO Framework Convention on Tobacco Control (FCTC), which sought to reduce it. This study aims to explore the scale and nature of the TTCs’ lobby against the EU TPD and evaluate how these developments have affected their ability to exert influence.

Abstract

Background The 2014 European Union (EU) Tobacco Products Directive (TPD) was negotiated in a changed policy context, following adoption of the EU’s ‘Smart Regulation’ agenda, which transnational tobacco companies (TTCs) anticipated would increase their influence on health policy, and the WHO Framework Convention on Tobacco Control (FCTC), which sought to reduce it. This study aims to explore the scale and nature of the TTCs’ lobby against the EU TPD and evaluate how these developments have affected their ability to exert influence.

Results The lobby was massive. PMI alone employed over 160 lobbyists. Strategies mainly used third parties. Efforts to ‘Push’ (amend) or ‘Delay’ the proposal and block ‘extreme policy options’ were partially successful, with plain packaging and point of sales display ban removed during the 3-year delay in the Commission. The Smart Regulation mechanism contributed to changes and delays, facilitating meetings between TTC representatives (including ex-Commission employees) and senior Commission staff. Contrary to Article 5.3, these meetings were not disclosed.

Conclusions

During the legislative process, Article 5.3 was not consistently applied by non-health Directorates of the European Commission, while the tools of the Smart Regulation appear to have facilitated TTC access to, and influence on, the 2014 TPD. The use of third parties undermines Article 5.3.

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Cigarette combustion, rather than either tobacco or nicotine, is the cause of a public health disaster. Fortunately, several new technologies that vaporize nicotine or tobacco, and may make cigarettes obsolete, have recently appeared.

Summary

Abstract

Cigarette combustion, rather than either tobacco or nicotine, is the cause of a public health disaster. Fortunately, several new technologies that vaporize nicotine or tobacco, and may make cigarettes obsolete, have recently appeared. Research priorities include the effects of vaporizers on smoking cessation and initiation, their safety and toxicity, use by non-smokers, dual use of vaporizers and cigarettes, passive vaping, renormalization of smoking, and the development of messages that effectively communicate the continuum of risk for tobacco and nicotine products. A major difficulty is that we are chasing a moving target. New products constantly appear, and research results are often obsolete by the time they are published. Vaporizers do not need to be safe, only safer than cigarettes. However, harm reduction principles are often misunderstood or rejected. In the context of a fierce ideological debate, and major investments by the tobacco industry, it is crucial that independent researchers provide regulators and the public with evidence-based guidance. The methodological and ideological hurdles on this path are discussed in this commentary.

Conclusion

A window of opportunity is now open but will soon close. In the United States, the Food and Drug Administration is developing regulations that will apply to e-cigarettes and vaporizers, and European Union Member States are now transposing the Tobacco Products Directive into national laws. Once these regulations are in place, they will be very difficult to change. However, because harm reduction strategies are often misunderstood or rejected [14], there is a risk that e-cigarettes and vaporizers will be excessively regulated. Regulators must consider the unintended consequences of excessive regulation, and should be held accountable for any such consequences. Given that e-cigarettes and vaporizers are already much safer than combustible cigarettes, any benefit of regulations will be small, whereas the unintended consequences can have a large negative impact. Unfortunately, current proposals for regulation are often worse than the status quo. It is sad that this is happening with the help of some public health professionals, scientists and elected representatives of the people.

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Review of 37 studies. It rejects recreational use of PVs, and mentions regularly the gateway effect. It recognises the potential as an aid for quitting tobacco, but recommends regulating them as other NRTs (i.e. pharma regulations).

Summary

Background: Electronic cigarettes (e-cigarettes) are battery-powered devices that vaporize a liquid solution to deliver a dose of inhaled nicotine to the user. There is ongoing debate regarding their regulation.
Objectives: This comprehensive narrative review aimed to discuss key issues including usage patterns, health effects, efficacy in smoking cessation and regulatory concerns with a view to informing future regulation and research agendas.
Methods: PubMed, Scopus and Web of Science databases were searched using the terms (electronic cigarettes OR e-cigarettes) for articles in English, relevant to humans and published during January 2009-January 2014.
Results: The literature search revealed 37 relevant articles. Findings suggest that e-cigarettes are mostly used by middle-aged current smokers, particularly males, to help them for quitting or for recreation. E-cigarettes contain very low levels of multiple toxic substances such as formaldehyde and acrolein, but these levels are many times lower than those found in cigarettes. They were found to have effectiveness in aiding smoking cessation to a limited degree.Debate continues regarding regulating their use for cessation versus heavy restrictions to control recreational use on
the basis that it perpetuates nicotine addiction.

Conclusion

The cytotoxicity and long term health effects of e-cigarettes are unknown. Nevertheless the e-cigarette market continues to expand, largely driven by middle-aged smokers who claim to be using e-cigarettes in an attempt to reduce or quit smoking. E-cigarettes may have some potential as smoking cessation aids and, in the researchers’ view, should therefore be subject to further research and regulation similar to other nicotine replacement therapies.

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As the most popular video sharing website in the world, YouTube has the potential to reach and influence a huge audience. This study aims to gain a systematic understanding of what e-cigarette messages people are being exposed to on YouTube by assessing the quantity, portrayal and reach of e-cigarette videos.

Summary

Methods

Researchers identified the top 20 search results on YouTube by relevance and view count for the following search terms: “electronic cigarettes”, “e-cigarettes”, “ecigarettes”, “ecigs”, “smoking electronic cigarettes”, “smoking e-cigarettes”, “smoking ecigarettes”, “smoking ecigs”. A sample of 196 unique videos was coded for overall portrayal and genre. Main topics covered in e-cigarette videos were recorded and video statistics and viewer demographic information were documented.

Results

Among the 196 unique videos, 94% (n = 185) were “pro” to e-cigarettes and 4% (n = 8) were neutral, while there were only 2% (n = 3) that were “anti” to e-cigarettes. The top 3 most prevalent genres of videos were advertisement, user sharing and product review. 84.3% of “pro” videos contained Web links for e-cigarette purchase. 71.4% of “pro” videos claimed that e-cigarettes were healthier than conventional cigarettes. Audience was primarily from the United States, the United Kingdom and Canada and “pro” e-cigarette videos were watched more frequently and rated much more favorably than “anti” ones.

Conclusions

The vast majority of information on YouTube about e-cigarettes promoted their use and depicted the use of e-cigarettes as socially acceptable. It is critical to develop appropriate health campaigns to inform e-cigarette consumers of potential harms associated with e-cigarette use.

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Highlights
• Tobacco harm reduction aims to reduce illness and death caused by smoking tobacco.
• The medical and regulatory consensus is that nicotine itself is relatively safe.
• Snus use in Sweden provides strong evidence in support of harm reduction.
• E-cigarettes are seen by many smokers as an attractive alternative to cigarettes.
• Regulated, safer nicotine alternatives may substantially improve public health.

Summary

Over the last 50 years, the concept of tobacco harm reduction has been well established. It is now understood that nicotine itself is not very harmful and nicotine replacement therapy products have been widely used as an aid to quit, reduce to quit or temporarily abstain from smoking for many years. The popularity of the unlicensed electronic cigarette has increased despite an unknown risk profile and snus use in Sweden provides strong evidence in support of a harm reduction strategy. The regulatory environment around harm reduction has changed in the UK and is continuing to evolve across the globe. The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. The significant positive impact on public health that could be gained from encouraging people to switch from cigarettes to licensed medicinal nicotine products cannot be ignored.

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Highlights
• There is now near universal awareness of e-cigarettes.
• Use is common among smokers.
• Quarter of all smokers unsure as to whether they are less harmful than cigarettes.
• E-lites – a brand that delivers a low dose of nicotine – is the most popular.
• Users have higher SES, smoke more heavily and have attempted to quit recently.

Summary

Background

E-cigarettes may be effective smoking cessation aids and their use by smokers has been growing rapidly. It is important to observe and assess natural patterns in the use of e-cigarettes whilst experimental data accumulates. This paper reports the prevalence of e-cigarette awareness, beliefs and usage, including brand choice, and characterises the socio-demographic and smoking profile associated with current use, among the generalpopulation of smokers and recent ex-smokers.

Methods

Data were obtained from 3538 current and 579 recent ex-smokers in a cross-sectional online survey of a national sample of smokers in Great Britain in November and December 2012. Differences between current and recent ex-smokers in the prevalence of e-cigarette awareness, beliefs and usage were examined and the socio-demographic and smoking profile associated with current use of e-cigarettes was assessed in a series of simple and multiple logistic regressions.

Results

Ninety-three percent of current and recent ex-smokers (n = 3841) were aware of e-cigarettes. Approximately a fifth (n = 884) were currently using e-cigarettes, whilst just over a third (n = 1507) had ever used them. Sixty-seven percent of the sample (n = 2758) believed e-cigarettes to be less harmful than cigarettes; however, almost a quarter (n = 994) remained unsure. Among both current and recent ex-smokers, the most popular reasons for using were health, cutting down and quitting (each > 80%) and 38% used the brand ‘E-lites’. Among current smokers who were aware of but had never used e-cigarettes, approximately half (n = 1040) were interested in using them in the future. Among current smokers, their use was associated with higher socio-economic status (OR = 1.48, 95%CI = 1.25–1.75), smoking more cigarettes (OR = 1.02, 95%CI = 1.01–1.03) and having a past-year quit attempt (OR = 2.82, 95%CI = 2.38–3.34).

Conclusions

There is a near universal awareness of e-cigarettes and their use appears to be common among smokers in Great Britain although a quarter of all smokers are unsure as to whether e-cigarettes are less harmful than cigarettes. E-lites – a brand that delivers a low dose of nicotine – is the most popular. E-cigarette users appear to have higher socio-economic status, to smoke more cigarettes per day and to have attempted to quit in the past year.

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Highlights
No firm conclusions can be drawn on the safety of electronic cigarettes.
The findings in the 76 studies were often inconsistent and contradictory.
Serious methodological problems were identified and there is no long-term follow-up.
In 34% of the articles the authors had a conflict of interest.
Electronic cigarettes can hardly be considered harmless.

Results

We included 76 studies investigating content of fluid/vapor of ECs, reports on adverse events and human and animal experimental studies. Serious methodological problems were identified. In 34% of the articles the authors had a conflict of interest. Studies found fine/ultrafine particles, harmful metals, carcinogenic tobacco-specific nitrosamines, volatile organic compounds, carcinogenic carbonyls (some in high but most in low/trace concentrations), cytotoxicity and changed gene expression. Of special concern are compounds not found in CCs, e.g. propylene glycol. Experimental studies found pulmonary obstruction after short-term exposure. Reports on short-term adverse events were often flawed by selection bias.

Conclusions

Due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up no firm conclusions can be drawn on the safety of ECs. However, they can hardly be considered harmless.

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We reviewed available research on the use, content and safety of electronic cigarettes (EC), and on their effects on users, to assess their potential for harm or benefit and to extract evidence that can guide future policy.

EC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking.

Conclusion

Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality. Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence. Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.